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Monday, August 3, 2009

When I was 13 weeks pregnant with my first child, I was teaching a summer course in Italy. One day at the Vatican, I was trailing at the end of our group, trying to make sure that the dawdling students (and how can you do anything but dawdle at the Vatican, when there's so much gorgeousness to see?) didn't get left behind by the very fast-paced leader of our tour. Busily ensuring we weren't leaving any students behind, I quickly got very far behind. While zooming to catch up, I tripped over something, went completely Superman airborne, and then crashed onto the marble terrace so hard that it knocked the wind out of me. Of course, my group was already so far ahead that no one noticed -- and they had divided in half to go to two different locations, so no one would notice I was missing, since each group would assume I was with the other. Gasping for breath, aching, and panicky, I rolled over and tried to sit up but could not. Some very nice Spanish tourists stopped to help me, and as we eventually walked slowly to the first aid station, my broken Spanish and their broken English managed to converge around the mutual understanding that I was pregnant and deeply concerned that I'd hurt the baby.

Within a few minutes of talking to the nurse on call, I was being escorted into an ambulance (which I didn't expect). A grandfatherly doctor who spoke no English was apprised of my situation, and for the entire ride to the hospital, he patted my hand and murmured gently to me in words I could not translate but which were clearly meant to be reassuring. The ambulance jolted over cobbled streets, siren wailing, and soon I found myself in the institutional-green hallways of a Roman hospital, stretched on a gurney, and trying to rest and calm myself until the doctors in OB could see me. See me they did. A very kindly female doctor gave me a complete exam and an ultrasound. The first strains of my child's heartbeat, thump-thumping strong over the monitor, finally quelled my panic and made me forget my already aching ribs and my developing bruises. The doctor told me everything would be just fine, handed me two small ultrasound pictures, and sternly forbade me to do anything for the remainder of the day but take to my bed.

Grateful for good news, I was only worried about one more thing. Where, I asked in a timid voice, where did I go to pay? The doctor looked at me confused. Was this a bill? I wanted to know of the blue sheet printed all in Italian that has issued from their computer. Where was the office to pay the bill?

The doctor finally understood what I was getting at, straightened her shoulders a little proudly. "Oh no," she said in heavily accented English as she waved me off, "not in I-taly."

And that was that. I took the bus back to my (bed-bug-infested) hostel, climbed into bed, and told no one what had happened. For the next few days, I walked more slowly, was extremely careful not to jostle my very tender midsection, and breathed serenely at the thought that the little life I was carrying was going to be just fine.

I have not read the current health care bill (all 1300+ pages), but here's what I do know: in a country without a national health care system, an ambulance ride, emergency visit with a hospital OB, and an ultrasound would have cost me many thousands of dollars. If I had been an Italian in the United States? The bill would probably have topped $10,000.

I know that people here who have pre-existing conditions will have to spend thousands of dollars each month on health insurance, if they can get insurance at all.

According to the last government data available (from 2007), nearly 46 million people in the US have no health insurance.

I know that many people without insurance cannot afford preventative care (like vaccines), and often avoid going to the doctor at all until the situation is desperate, in which case they are far more likely to end up in the ER and/or needing treatments much more expensive than either preventive care or timely doctor visits would have cost.

I know that hospital expenses are absurdly high, and the current system doesn't help matters. Because hospitals cannot turn away emergent cases on the grounds that people can't pay (read: if you show up with a compound fracture from a car accident, they are bound to fix your leg regardless of your insurance), the people who can pay are charged more. (This is not the only reason for absurdly high hospital costs, but it is an important one, I think we need to remember.)

I know that we spend huge amounts of money in this country on expensive tests and treatments that have a very small likelihood of succeeding, but doctors order them anyway because the way the system is structured, the financial incentives are greatest for trying anything and everything rather than curing people quickly. (Read: doctors make more money the more procedures they try, rather than getting a bonus for curing you.) This is not at all meant to imply that doctors don't try to cure patients as efficiently as possible, but rather to say that a system that has an incentive built into it to try even very expensive treatments that are very unlikely to work, rather than an barrier to authorizing such folly, is a problematic system.

I know that people who lose their jobs through no fault of their own also lose their health insurance -- at the very time when they can least afford the expense of an unexpected health emergency because, um, they just lost their jobs. And then, of course, when they find new jobs, they may find that they are not eligible for coverage through their new employers because now that thing that was being managed quite well, thank you, by their previous doctors and insurance (say, a pregnancy halfway through, or an asthma that needs regular inhalers) is suddenly a pre-existing condition.

I know that a system in which my insurance has negotiated a rate for a routine hospital stay (such as labor and delivery) that is 1/4 of what the actual bill says -- and therefore 1/4 of what someone without insurance would pay -- is absurd and criminal. Why should the bill be different for me and for the woman in the next room?

I know that I am one of the lucky ones. I have a secure job that comes with a great and extremely affordable health care plan.

I know that if a national health care plan is passed, the costs of my health care will certainly rise because right now, they are artificially low as this benefit is part of my compensation package (like salary and other benefits).

I know that if a national health care plan is passed, my taxes will probably rise, since something needs to give if all the people currently denied health care in this country are to have access to it.

But I also know that I am somewhat ashamed that I benefit while others suffer because we live in the only first-world country on the planet that does not consider the accessibility of health care to be a basic human right.

I know that I am horrified when I hear stories of people whose children's illnesses bankrupted their family.

I know that something must change.

I do not know if the current health care bill has all the answers, and somehow I doubt it does, since I would imagine that an overhaul of our current bureaucratic system will take more than one try.

But it is a start. And we must have a start.

Because every single day, and every time my kids get strep throat, or fall on the playground and might have broken their wrists but turn out not to--and I can be sure of that because they got x-rays within hours of the fall, or get their teeth cleaned or their eyes checked, or get vaccinated, or have a dresser fall on them and need to be examined for internal injuries...and I get to see a doctor that very same day because I have insurance...I am thankful that I am one of the lucky ones.

And I mourn for those who are not so fortunate.

My taxes will go up. It will cost me, personally, more. But I passionately believe we must have a national health care system.

Because I feel that among the privileges of living in one of the richest nations on earth comes the obligation to be sure that those among us who are not the richest never have to watch a child die from something preventable because they were afraid the rest of the family would not be able to eat after the hospital bill was paid.

It needs to be a system carefully devised and executed. It needs to be a system that will actually work as intended. It needs to be a system in which health care is not a condition of employment and in which pre-existing conditions do not make you ineligible for care. It needs to be a system that I am not well-informed enough to design, but that I am willing to pay for.

Because, quite honestly, it is morally problematic that anyone should be able to write, as I do:

I am so glad that you are writing about it. I wrote about it a few weeks back, because I feel so strongly about it. I wish more people, safe with benefits (supposedly, I guess you never know what will happen) saw it the way you do.

I will not pretend to know the ins and outs of the US healthcare system, nor do I know the implications of taxation to pay for such a system. But I do know that I agree 100% with this:

"Because I feel that among the privileges of living in one of the richest nations on earth comes the obligation to be sure that those among us who are not the richest never have to watch a child die from something preventable because they were afraid the rest of the family would not be able to eat after the hospital bill was paid."

You brought tears to my eyes with this post. I strongly agree with you. This quote will forever be in the forefront of my mind: "But I also know that I am somewhat ashamed that I benefit while others suffer because we live in the only first-world country on the planet that does not consider the accessibility of health care to be a basic human right."

I know that we spend huge amounts of money in this country on expensive tests and treatments that have a very small likelihood of succeeding, but doctors order them anyway because the way the system is structured, the financial incentives are greatest

Let's not forget the tort system is so structure that a doctor would be sued within an inch of their life if they didn't perform EVERY test under the sun.

Please allow me to tell you a story: I know a couple who have two children, boys, both with chronic and very expensive medical issues. They both need physical and speech therapy. They both attend programs provided by the state. For both children, the game plan laid out by the PT was to enable the boys to roll over, and that pretty much stopped. By 3 years old, their PT was said to have been accomplished, because that was the standard they were to meet.

The father of these boys does a Herculean effort to afford private care. His boys are running around and doing well -- certainly not perfect by an outsider's point of view, but perfect still by the parent's standards. Even after the advancements that were hard earned by the private PT were shown by the boys to the state PT, the state programs remained fixed and unchanged: they were prevented from advancing, even though they were walking about (later running), the state PT focused on rolling, and wheel chair use.

With regards to ST: the same thing - basic speech (food, milk, eat, sleep), but no real communication. Speak to the boys after 2 years in private PT and you're hard pressed to know they ever had a speech issue.

Here's the rub: if the private PT/ST did as piss-poor job as I described above, the parents would find another provider.

Since the state runs the state-provided care, who do the parents turn to in order to get a better PT?

Examples likes this that I know and can see with my own eyes are why I will fight to my dying breath NEVER to let the state have absolute say over my children's health-care.

Wow, beautifully said. You said everything I've been thinking much better than I ever could. I went for nearly 10 years without insurance in between being too old for my parent's and getting my own. Luckily, nothing horrible happened, but I remember how awful it was to be sick and not be able to afford to do anything about it. I complain about the insurance that I do have because they do their best to not pay for things, but I always follow it with "but I'm thankful to have insurance at all." No one should have to say that. No one should have to make healthcare decisions based upon finances. I agree with everything you wrote!

I had a similar experience in Athens, Greece when I was studying abroad in college and got a terrible lung infection that required a trip to the ER. I could not believe that I did not need to PAY. Not even for the interpreter.

However my husband and I cannot afford to have maternity coverage of our own because I am married and chose to go about bringing babies into this world with a little more responsibility.

How is that fair?

Because I played by all the rules I don't get to have a baby because I'm not willing to go into debt to get one but some fourteen year old who can't keep her pants on can have a baby for free?

Really?

Not everyone without insurance is a louse. My husband chose to go on and get higher education. For the next few years we should just sit idly by crossing our fingers that we don't get sick because we can't afford it if we do?

I think an awful lot of people have been spoiled with their insurance and are a little too selfish when it comes to negotiating this plan.

My kid knocks out a tooth today? We come thisclosetobankruptcy. Only you can't bankrupt out of student loans.

Sure the cutoff in Indiana for state assisted healthcare is $35K and my husband will be making $50K. But when is anyone going to take into consideration that we are paying $20K in student loans back each year?

Really.

It's not screwed up at all.

Sorry.

This is a very open and tender wound for me right now.

Thank you for being able to see that people who would benefit from a national healthcare policy are real people with families who do in fact deserve better.

We have health insurance, but will still put out over $20,000 in medical costs THIS YEAR. Having a sick kid means that even with insurance, you will damn near go bankrupt. Something needs fixed. Soon. Actually, now would be good.

Very interesting, and clearly something you are passionate about. As a healthcare professional, and the wife of a physician, I too believe that people should have access to healthcare.

HOWEVER, there is a correct way to do things, and there is just pushing through any old plan. I urge you to get familiar with some of the details of this current proposal because while "health care for all" sounds very rosy, the reality of it and the consequences to our country are very large. Do we want our children to just be insured at any cost, no matter the large debt they will likely inherit?

I also do take some offense (though I know you meant none) against physicians testing patients to their profit. My husband spends lots of office hours (as a cardiologist) trying to convince patients they do not need tests that they request, at the peril of the person going elsewhere (and they will) or worse, suing him.

The system needs to be overhauled, I doubt there is anyone out there who disagrees on that point. I just think that people really need to be careful and do research before declaring this particular plan "the one".

There are lots of great comments here, and I'll try to respond personally via email, but I wanted to respond publicly to the point Charlie makes.

I think it is an excellent point that everyone on BOTH sides of the question would do well to keep in mind: when systems that don't have the best interests of patients in mind get to make decisions about health care, invariably the best interests of patients are not always served. HOWEVER, I know people who have faced similar frustrations of care being limited because their insurance refused to pay any more and the people couldn't afford the completely private programs that insurance would not cover. This happens all the time in terms of mental illness care, for example. Or, as MomoFali's situation suggests, when one has "maxed out" the coverage one can afford. Whether the state or the insurance company is making the call, then end result is the same: only people with extensive financial resources can get past the limits instituted by bureaucracy.

I don't personally think this is a reason not to institute a universally-accessible national program.

Because, under our current private insurance system, we already have the problem you identify as being due to state control, one can only hope that the design of a national system will attempt to correct not just the problem of those without insurance but also the problems of under-insurance and the current absurdities in differing standards of care for people with different abilities to pay.

I do not say the current bill is the right one, only that stopping at "we shouldn't try to craft the right bill" seems to me terribly short sighted.

Lindsey, you are totally right, and I struggled hard writing that paragraph to make it say what I meant. What I meant was NOT that physicians try to bilk patients by ordering useless tests but rather that the SYSTEM has built in more incentives for expensive procedures so that patients come to expect EVERYTHING will be tried even when some things are really not warranted.

Also, your point that doctors can, and will, be sued by patients for not doing procedures that the doctors don't think are best but that the patients are convinced might work is an excellent one. What I hope I am conveying here is that the SYSTEM is broken, with both incentives and blame in some of the wrong places.

That said, I am trying hard to refrain from commenting on whether I think this particular bill is a good one or not, since I am not familiar enough with it to feel like I can make an informed response (though I do intend to try to become so informed). Thank you very much for your perspective.

the first comment on this page is about a soon to be mother in italy. everything was fine and i am sure she got a bill after her insurance took care of it. but this is a perfect example of a well care system. there are no heart defects to fix no spinal defects to fix with her child. had there been it would have been a new bag of tricks.she didnt need surgery she was okay. talk to the people who need a heart transplant and are sent home on lvads an external mechanical heart to die at home because there is no priority put on transplants. talk to a mother who wants her child to have heart surg but the well care system in thier country says not for 10 years and they watch there child fight to live every day. how about the 50 year old man who is wheelchair bound because a simple knee replacement is put on the back burner. i was in london two years ago, i asked our cab driver how he like socialized meds he said it was great. he had kidney stones, it only took two years to get it taken care of one year to get into the doctor and an additional year to get surgery. in the u.s. we treat our dogs better than that!!!! so those who are for it how long can you stand the pain of kidney stones how long would you let your parents or your children?????

I do agree that something needs to change, but I don't agree that this is the correct plan for our country. Instead of once again throwing money at a problem, which I have come to understand is another Trillion dollars, why don't we focus on fixing the flaws?

I myself do not want my government involved in my health care choices, and I say this as a fomer military brat who grew up with decent army medical care.

A great article that focuses on a few points can be read here. I thought it was helpful. My main upset is that the politicians keep glossing over the fact that within five years we'll all have to be on this new plan. I find that very upsetting.

I have no idea what the right and proper answer to the Health Care question is - but I DO know this: We are the only industrialized country in the world where medical expenses can bankrupt a person or a family. Where you can lose your home to medical bills. We are SUPPOSED to be the richest country on earth. Why can we not find a way to take care of each other?

Thanks for providing a reasonable reply (you have no idea how many times I've had my head virtually cut-off for speaking against the public plan).

Before I answer your direct reply, allow me to remind everyone that should you have been a visitor for Italy (using the reverse of your story as an analogy) and was injured at the Metropolitan Museum of Art, your care would have been provided for by the tax payers (just ask any illegal alien). So it's no different.

Now then: we in the US have become too coddled. Yes, I said it. My parents and grandparents lived through The Depression, and they know well what it's like to lose everything. That's why should I face losing everything in the name of providing care for my family, I will do it... because material things are meaningless compared to family.

So yeah, I'll go bankrupt and do whatever I have to to get by. And the pharmaceutical companies will provide their meds (as they have for decades) even though I am indigent. And I will remain in charge of my families' care, without the government bean counters standing over me. Many have criticized the insurance companies limiting care: so you think Uncle Sam rationing care is somehow better?

My uncles served in WW-II and in Korea; they know far too well how the VA has failed many of their brothers when they needed healthcare (and the VA has had barely passing grades for over 30 years). If the US Gov't can't adequately deliver proper healthcare to small subset of the population (i.e. veterans), who really thinks it can deliver for all of the population?

Answer: it can't.

Want to know what scares me almost as much as this healthcare bill? That most in Congress haven't read it. I have. I work 40 hrs/wk, spend 20 hrs/wk commuting, and am a father, and I found time to read the monstrosity. That a ranking US Senator from my own Commonwealth, Arlen Specter, claims he's too busy to read it is an insult to his constituents and the American people as a whole.

I've read it, and it scares me. If as they claim they have no time to read it, why rush it? Why not take the time to read it? Perhaps the devil is in the details, and that's why they want to push it through.

You may think the current health care in America sucks, but tell me: how many people leave the US for required surgery each year? Then tell me how many people come to the US for surgery?

Charlie, on some things, I could not agree with you more. It is completely terrifying that people voting on this bill haven't read it. If I haven't, then at least I can reasonably claim that I'm not sure whether I'm for or against it (and something tells me that even though I support a national health care system, there are certainly things in that bill that I would not support). If I were voting on it, however, you can be darn sure I would read every word. And I expect my Senators to do the same.

And you are 100% right that VA care has fallen abysmally short for too many veterans, and I can only hope that a new system overhaul will help to fix that too.

On your point, though, that you would prefer go bankrupt if you had to in order to take care of your family's medical expenses, rather than have the government manage anything, I have to say this: while I applaud your fierce and impressive independence and fortitude, I am of the opinion that no nation should ask such sacrifice of its citizens. On this, I suppose, we may have to agree to disagree.

We can agree to disagree there, but to only a point: I don't hope to be reduced to going hungry while my kids have scraps. But I believe that what makes this country great is that you can be that far down on your luck and still survive, and indeed succeed again. I point to my grandparents and parents who lived through the Depression and thrived afterwards.

There are no guarantees in this world, and I don't think there should be any; I guess that's the lynchpin of my philosophy.

Well said.I agree there needs to be changes made.Changes we all can live with from newborn to geriatric.Changes that reflect that we are, were or may someday be an asset to our families, community..country.Changes that would never consider us to be a liability or a drain on the system.Changes that take into account that we are all deserving of this basic human right.

No one that I know of could have articulated this as elegantly as you did. I admire your willingness to tackle such a hefty and heated topic.

Having said that, I am not in support of a nationalized health care plan for the simple reason that I have immigrated to a country(the UK) where socialized medicine is the norm and the things I saw, heard and went through personally have forever shaped the way I feel about this. My own husband, who is British, feels so strongly against the US having any form of universal health care that he's decided to naturalize (we are in the process of it as I type) so that he can cast a vote in support of someone who has a better plan...a plan that includes the uninsured but that is NOT run by the US gov't.

There are a myriad things that go into the reasons the delivery of our current health care system does not work, one of the biggest being a total lack of meaningful tort reform. Until that happens, it will be litigation that helps raise the cost of insurance premiums including malpractice premiums, thus raising the cost of health care.

The thing that disgusts me most about Obama's rhetoric about his health care proposal is that he is not being transparent or open about what the end result of the proposed plan means. The most disappointing aspect of this plan is that we will in face loose our choice of health care providers and we will in fact head towards rationed health care. I've been down that road with a serious knee injury whilst in the UK and I never want to have to go down it again with something worse like a recurrence of my breast cancer.

Whilst I agree that we need to have some sort of health care option for the uninsured, I disagree that it needs to be the gov't that provides or runs it.

Therein lies the problem. And I'm not just singling you out, either. A lot of people, a lot of our congressman, haven't read the bill either and when it comes to something this important, THIS life-changing (for any decision on this magnitude will affect decades of future generations - our children, our grandchildren), I think it's crucial to read, and understand, the proposal first before making any decisions, rash or otherwise. (And the fact that the bill IS that long to begin with is suspect -- who is going to (carefully) read a bill over 1000 pages long? The more complex and confusing they make it, the more they're counting on people NOT reading it and pushing personal agendas through the system)

Here is breakdown of the bill: http://bit.ly/dcBEO . It's a gloomy forecast at best. We owe it to our future generations to READ this bill, to UNDERSTAND it, and to IMPROVE it.

There is no question that our current system needs a major overhaul. But to take choices away, squash competition and allow the government to take over something as vitally important as healthcare, when it's been proven, time and time again by other government-run programs that anything government controlled is inefficient and ineffective, is irresponsible.

Please understand, it's not about US versus THEM. It's not about Republicans versus Democrats. It's not about the privileged versus the non-privileged. It's not about FEELING versus FACT. It's about getting it right. It's about finding, and implementing a program that is fair and useful to everyone without taking freedoms away in the interim.

I understand the need to make our healthcare system better, it really is a colossal mess right now, but passing this bill through, without reading it, without fully understanding the repercussions, is irresponsible.

Vaccinations can always be obtained, free, from public health clinics. Prenatal care and STD screenings and treatment can also be obtained free there. My mother spent many years as a public health nurse, which is why I know this. It's a small point in the scope of things, but just in case someone here doesn't know that and needs to.

I would also like to put out there that among my many issues with the proposed health plan is my concern for what government standards will do to alternative medicine. We have nice insurance now (we didn't for the first 6 years and 2 babies), but we are still paying, out of pocket, to have a midwife birth at a birth center, rather than an hospital birth. I am very passionate about birth being natural, normal, and not requiring (in most cases) all the loud and invasive stuff that comes with a hospital. I have problems with the required vaccination schedule advanced by the CDC. Right now, I can choose a midwife; I can find a pediatrician who will work on a different vaccination schedule with me. I can make the choices that I think are right for my family's health. What will happen when the government is setting the standards? Powerful lobbies from the drug companies and the AMA will push alternative medicine and choices out. We will all be required to conform. That is unacceptable.

i, too, do not know the details of this current health plan, but have been inspired to learn more, now!

i don't know what kind of system singapore has, but i know that there is a public system that anyone can use and pay very little(and the clinics have longer waits, no air conditioning, etc), and there is also a private system where, if you can pay, you can do pretty much whatever you want.

one of my sons was born in singapore and our total cost for prenatal and birthing costs (no complications, 3 days in hosptial; private) was $3000 (our insurance covered 80% for out-of-network).

my other son was born here and the invoice we got from the hospital was well over 12k (our copay was $15 for the initial dr. visit).

both pregnancies were normal, induced labor with epidural. as far as i'm concerned the experience was pretty much identical with respect to level of care.

I have a question for those who look to other nation's health care as an example of what could work in the US:

What kind of liability do the health care providers have for those under their care?

I've heard of all these benefits in other nations, but what would happen if an actual malpractice occurs while you're under the care of one of these other-nation providers?

I am all-too-aware that stuff happens and there are unforeseen complications and whatnot, and I am specifically not talking about that. I want to know what recourse a person has in the event of malpractice in Canada, UK, Singapore, etc.

With all due respect to Charlie and Mommytime the claim that the VA provides poor care is absolutely not true. There has been numerous studies published in the last decade in the top medical journals (e.g., New England Journal of Medicine and Journal of the American Medical Association) that has shown that the VA provides better care than many of the top health care systems. In these studies, they compare "quality indicators" across different hospitals and find that the VA provides excellent care. Perhaps 50 years ago things were different. But right now, the VA provides excellent care (which is also shown in surveys of patients).

Since you doubt my telling of my uncle's experience, I will provide the following points of fact:

Exhibit AFor patients with prostate cancer, it is a common surgical procedure: a doctor implants dozens of radioactive seeds to attack the disease. But when Dr. Gary D. Kao treated one patient at the veterans’ hospital in Philadelphia, his aim was more than a little off.

Most of the seeds, 40 in all, landed in the patient’s healthy bladder, not the prostate.

It was a serious mistake, and under federal rules, regulators investigated. But Dr. Kao, with their consent, made his mistake all but disappear.

He simply rewrote his surgical plan to match the number of seeds in the prostate, investigators said.

The revision may have made Dr. Kao look better, but it did nothing for the patient, who had to undergo a second implant. It failed, too, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.

....

Peer review, a staple of every good hospital, in which colleagues examine one another’s work, did not exist in the unit. The V.A.’s radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene; either their inspections had been limited or they had not acted decisively upon finding problems. ...

http://www.nytimes.com/2009/06/21/health/21radiation.html

Exhibit BAirman 1st Class Colton Read was supposed to get his gallbladder removed laparoscopically - via a small incision - at Travis' David Grant Medical Center on July 9.

During the procedure, surgeons nicked or punctured his aorta, a large artery that carries blood from the heart throughout the body, according to his wife, Jessica Read. The surgeons repaired the breach enough to save his life, but the repair began leaking and disrupted the blood supply to his legs, she said.

Read was flown to UC Davis Medical Center in Sacramento, where doctors told the family that damage from the lack of blood required amputation. Family members say he's undergone 10 surgeries to remove dead tissue from his legs, leaving him without much of his right leg and the lower portion of his left.

And Read still hasn't had his gallbladder removed because of the surgery complications, relatives said.http://www.military.com/news/article/airman-loses-legs-after-gallbladder-surgery.html

That's simply 2 recent events that made national news. With all due respect, I'll put the word of my uncle's friends, the first-hand information I hear in my employment as a Defense Contractor, and the sourced stories like the above against your position.

I know of the brachy scandal at the Philly VA and that is a tragedy. There is no excuse for that type of medical care. But it doesn't happen just at the VA, these types of things happen at many hospitals.

The other example is not as good given that physicians at all hospitals make errors. Do you think that even at the Mayo or Cleveland Clinic these types of events don't occur? They just don't make front page national news.

To be transparent, I am a scientist and I think data based on thousands of cases and surveys of thousands of patients and their experiences with the VA is more valid than anecdotes of people I know. I don't mean that snidely or rudely. It's just the type of person I am.

In case you think I am just spouting off...let me give you some of my sources (you don't know me, so no reason to trust that I know what I am talking about. I apologize for not providing sources earlier...I am supposed to be working :-)

In fiscal year 2000, throughout the VA system, the percentage of patients receiving appropriate care was 90 percent or greater for 9 of 17 quality-of-care indicators and exceeded 70 percent for 13 of 17 indicators. There were statistically significant improvements in quality from 1994-1995 through 2000 for all nine indicators that were collected in all years. As compared with the Medicare fee-for-service program, the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators.

Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample

Thank you for the sources; I will check them out, and hope to somehow resolve them against the first-hand references I've gotten from my experience as a Def. Contractor, etc. (I'll leave Mommytime to defend her own position).

But now I wish to link our dialouge with the question I put forth before your initial post today:

tell me what recourse do either of these VA patients have, now that the federal government-provided healthcare have crippled them?

While I support a substantial reformation of tort law in this country, here are two blatant malpractice cases. These two men have NO RECOURSE. Malpractice at Mayo clinic? You can be sure you'll have a healthy judgement in your favor (provided proponderance of evidence, etc.).

I think you raise the million dollar question. I wish I could answer that. I think here we would agree...there are lots of frivolous lawsuits (and thus overtesting, too many procedures etc), yet when true malpractice occurs (not just a human error but a history of poor performance or truly malicious treatment) something should happen. The patient who is harmed should have some recourse.

I think you wrote a very eloquent post and it got me thinking a lot....so I thank you for that. Your points are vlid and well articulated. I appreciate that Italy had a good system in place for what was a minor injury for you. But I agree with others in that I DO NOT want the government in charge of my healthcare or that of my children. Each of my children has a chronic medical need (allergies asthma, stomach issues) and I have sought all kinds of treatments from doctors all over this country..yes because I can afford too but also because I research doctors and methods and treatments (some "alternative"). I do not want anyone telling me that I cannot see a certain doctor who is THE BEST in the stomach problem that my child has...he would have likely died otherwise. When the government "runs" anything it becomes subpar in this country. I agee that everyone needs access to good healthcare but this bill is NOT the answer.

My personal feeling is that it's all moving way too fast. If President Obama and the supporters honestly feel like this is something good for the entire nation, than speak UP. Convince us that this is a good plan - don't just try to convince us that reform HAS to come. I think we can all agree that something HAS to be done, especially when it comes to controlling costs.

This is important. It cannot be ignored. And like you, I don't beleive they can get it all "correct" the first bill around, but a step is a step.

I guess I'm having a crisis of faith. Faith that anyone in Washington truly cares and is on the up and up, faith that my PKU son will not be forgotten in this entire mess (when you're 1/15,000 births, you don't rank that high when it comes to government sponsored medicine or private for that matter), faith that palms are not being greased, dirty promises being made, other promises being broken.

I envy the faith I see in the people who support this bill. When the government has mismanaged so much, what evidence is there that they will get this right?

Brilliantly written and argued. I agree with so much here and have reservations about some things, fears about the government running anything well mainly. This is also one of the most interesting comment streams I've read in a long time! Way to inspire rational discussion.

I have no point, I just think you're great. Oh, except we just got the bill from the hospital for the birth of our baby and my blood transfusion. The bill was OVER $13K, our insurance co will pay their contracted rate, more along the lines of $4K. That is wrong, our current system is set up to hurt cash payers AND milk the government (b/c gov programs often can be charged the same price as that charged to cash payers). It needs fixing.

I am overwhelmed and impressed with the thoughtful, detailed comments and conversation here. Thank you all, so much, for being willing to offer up differing points of view and really make me think about what I believe and know and what I still need to learn.

There are a few points I want to respond to publicly.

OHmommy: my understanding of the current legislation (someone here please correct me if I'm wrong) is that the reason members of Congress don't have to start out using this govt health care is the same reason that you don't: they and you already have insurance. The plan is meant initially simply to provide coverage for those who don't have any, so ANYONE who is currently insured has the option to retain that current insurance. I do not know all the details of how/when this will phase out, or if it will remain a two-part system, but what I have heard so far (based on news reports, NPR, etc.) is that there is nothing in the bill that indicates that we will all be mandated to have the identical government-provided coverage any time in the near (or even distant) future. But, again, this is something I am relying on reporting on, so I need to research it more.

This leads to my second point, one which a number of you have raised: the devil here is, most certainly, in the details. This is a complex and tremendous piece of legislation, one that will affect us, our children, and the country as a whole for generations. As such, it is not something that should be rushed through, voted on lightly or without vigorous debate of the facts, not just the emotions (to pick up on what WritefromKaren said). It is something we should all understand, and it is legislation we have the right to expect our Senators and Congresspeople to understand before they vote either way on it.

To the Charlie/Angie question of VA quality of care, I can only say mea culpa in terms of my own response agreeing with Charlie. I had in mind last year's scandals over care at Walter Reed hospital, mistakenly thinking it was a VA hospital, when in fact it is a DOD facility. As such, I will have to bow out of making any kind of claim about VA care either way, since I am clearly not well-enough informed about it. HOWEVER, I do agree with you both that there needs to be accountability for negligence and gross errors in government-run programs too -- and what recourse one currently has or might have under the new plan against such problems is not something I can answer.

I do want to say--and this is a matter of belief, not "fact," I suppose--that I believe that people should not have to go bankrupt or sell homes to pay for health care, that, in short, it should be a right and not a privilege when one lives in a rich nation such as ours. I respect that not everyone agrees with me, but I stand by the fact that I believe this.

And I thank you all, so deeply, for continuing this debate and discussion with me and each other. It has been (and I hope will continue to be) really eye-opening.

but what I have heard so far (based on news reports, NPR, etc.) is that there is nothing in the bill that indicates that we will all be mandated to have the identical government-provided coverage any time in the near (or even distant) future.

Read page 16 of the bill: should you have any changes in your existing coverage (say you change jobs, or your company decides to abandon their company plan, allowing you the 'choice' to take the federal plan) you are prohibited from continuing the current plan, or buying into a plan offered by another job.

I guess NPR - like many on Congress - hasn't read the bill either.

the devil here is, most certainly, in the details.

Indeed it is: where else in the 21st Century of enlightenment (with the administration of Change) do we refer to people with a variety of mental health issues as retarded? Why on page 389. But then, we have a President who makes jokes about the Special Olympics, so it's no big deal, right? (Ask any parent of a kid in Special Olympics if they were laughing)

Walter Reed hospital, mistakenly thinking it was a VA hospital, when in fact it is a DOD facility

Ah yes, I can speak volumes on this. As a Defense Contractor, I know well about BRAC - Base Realignment and Closure commission. An animal designed by Congress in the joy of the post-Soviet Union/End of Cold War age.

The BRAC Commission meets regularly to review military installations (including Walter Reed Army Hospital) and make recommendations for consolidating/closing un-needed bases. Their list is sent to Congress, and each house gets one vote (all or none), and then the President gets to sign the bill or veto it -- no sacred cows.

Walter Reed was BRAC'd 5 years ago (I believe, give or take). We've been at war for 7 years. Yeah, do that math again.

Any base that is BRAC'd has an almost zero chance of getting new funding without a congressional mandate. So even as our brave soldiers rolled in, they had to pull teeth with Congress to get additional funding to care for them because, after all, the base is set to close.

The BRAC machine rolls on, with no one having the will to stop it (no the Congress of 4 years ago, and certainly not today). It certainly could be justified back in the early '90s: we didn't need quite so many bases once we defeated the Soviet Union. But times have changed.

Once again: a government program run amuck. And people still WANT to turn over their healthcare to the government?

Being an expat (American living in the UK), I've experienced both systems. At first I thought I was getting "sub optimal care" in the UK but after several children and operations in both countries I have learned to love and respect the NHS. Especially the comfort of knowing it is there for my family (without the huge bill and paperwork).

Nobody wants to pay for it - and therein lies the problem. yet if we all shouldered some of the burden, it wouldn't be that hard. There is an expression which defines one of the planks in the platform of progressive politics: Spend the common wealth for the common good.

This has been an awesome post. But more important has been the comments and the dialogue that has emerged. I have read each and every comment and I say thank you to this level-headed and well-balanced discussion. It has been inspiring.

I agree with parts of both "sides" of this argument. I can totally relate to Moosh in Indy who articulates that a hard-working family should also have the basic right of health care. We are that family too.

But I also do not believe in handing over my care to the government. That to me is frightening.

I completely agree with Charlie in that I want control over my health care and my family's care.

We need an overhaul obviously on a system that is not providing enough quality care for the investment involved. My husband and I both work freelance so we have our own individual health plans for our family of five. And it costs a fortune. And it covers not as much as we would like. Having our babies cost us over $5000 a kid and that is with "good" insurance.

Yes, we need to help people and children especially who are uninsured. LOTS can be done in the realm of preventive care I believe - but I believe in choice and opportunity and sorry folks, I don't believe the government can be in charge of my choice or opportunity when it comes to my health.

But a step is a step and let's keep the dialogue and the passion alive....

I am probably a little too late with this comment, but I heard something yesterday that I thought was a great idea.

Right now states require insurance to have various different coverages, regardless of the needs of the consumer. They require those who don't want children to pay for In Vitro Fertilization and Well-Child coverage. They make women, and men who aren't afraid to be bald pay for hair prosthesis coverage. They may those who don't drink pay for alcohol abuse treatment coverage. Some states make atheists pay for coverage of pastoral counseling. They make those who don't believe in alternate medicine pay for coverage of chiropractors and acupuncturists. State coverage mandates increase insurance premiums by 20 - 50%, and are used by politicians as a way to reward lobbyist and make insurance consumers pay for it.

If the government would remove those mandates and let insurance companies craft, and consumers purchase plans that only cover what they want and need coverage for, insurance premiums would drop, a lot, not only from decreases in unnecessary coverage, but from market competition, and many more people would be able to afford insurance.

So many comments have said we need to take a step. Well this is step, that would solve the issue for some, but without creating a huge bureaucracy that will be nearly impossible to get rid of or change.

And best of all, it wont cost taxpayers a dime. Which is really important as our debt is increasing rapidly. If we continue to increase our debt this rapidly, China may consider us an unwise investment and stop giving us loans. Then we will have NO money to spend on health care or anything else without inflating our currency into uselessness.

This is a great site you have. I have a paranormal blog myself and I would like to exchange links with you. Please let me know if this is possible. You can contact me through either email or simply by a comment on my site. Talk to you later. Jason

And question for all of you who are pro-health care reform? Please, I really want to understand this point. No one has answered this from Charlie's post before.

We all know that insurance companies have lifetime maximums - and ration care to some extent - what in the world makes you think that the government won't do the same exact thing? Do you really think that all your medical issues will be paid for from birth to death??

I would think that with a potentially larger pool of people to insure that rationing of care would exponentially rise in order to accommodate everyone.

I agee wtih you completely. I do not know what the answer is, but this system is NOT it. If insurance companies would behave morally, insure everyone and deliver decent benefits without crazy exclusions, then we wouldn't be in this situation. But they won't and we are. My husband is uninsured and my insurance through the CATHOLIC CHURCH is just awful. A family plan is so expensive that we just cant' afford it. He is type 2 diabetic and we couldnt even get 12K worth of life insurance on him (DENIED) let alone health insurance!

Charlie, I would never accuse you of lying. Politicians on the other hand...well, they've been known to dissemble, shall we say.

Anon, on the question of rationing care and whether I really expect a government program would cover all of one's medical needs from birth to death, I can only answer: yes. Now, this is not to say that such care would cover every elective procedure. But, as you point out care is currently highly rationed on the basis of who can pay, I think that such decisions about what care to give when would be far better made on the basis of how urgent a person's medical needs are.

Lisa, I think your idea is an interesting one, and I also think that Lee's point about preventive care is excellent. In short, our country really needs to keep talking about this.

For those who question the cost and problems of bureaucracy of a government plan, I would urge you to read this article aimed at debunking some myths about how the Canadian system works. I found it very thought-provoking.

With all the talk about "death squads" doling out treatment this week some sectors of society seem to have forgotten we already have death squads in the American medical system. They work for the insurance company and their jobs are to determine when to refuse to insure individuals and to whom to deny payment of claims.

I know I'm a little late to the party, but as an attorney specializing in heath care matters, who actually has read the proposed bill and has been trained to understand just this sort of "legalese", I wanted to set the record straight on one of Charlie's comments on the bill itself.

Read page 16 of the bill: should you have any changes in your existing coverage (say you change jobs, or your company decides to abandon their company plan, allowing you the 'choice' to take the federal plan) you are prohibited from continuing the current plan, or buying into a plan offered by another job.

This is an incorrect interpretation of that section, which is actually simply defining what "grandfathered health insurance coverage" means. All Section 102(a) is saying is that in order for a plan to be considered a GHIC plan (which has a context in a few other places that I'm not going to get into here, but basically excludes such plans from being subject to the requirements of the bill), a plan can't enroll new participants after the date that the grace period for phasing in the government mandated requirements begin (except for dependents of existing plan members).

This is a rather innocuous part of the bill, and Charlie's misquoting and misinterpretation of a small segment of a huge bill as a scare tactic is exactly why I think all of these calls for people to "read the bill" are not only likely to be useless or counterproductive (as demonstrated here), but likely to be damaging to the process. Of course, everyone should feel engaged and become informed when a policy matter of this import is at stake. However, there is a reason I spent three years in law school and many years thereafter learning how to master documents like this, and that was so I could interpret them for clients and other lay people in terms they could understand. Now I'm not saying that it takes a legal degree to understand this bill, nor that everyone should hire a lawyer to interpret it for them, but those of you who aren't accustomed to these sorts of documents should realize that it does take a certain amount of patience and analytical ability to parse through 1,000+ pages of text that includes terms defined 700 pages back and obscure cross-references, and not everyone has that ability. Nor can a document like this ever be summed up by a single quote, whether in or out of context. Just a reminder that a little thoughtfulness goes a long way when it comes to trying to understand what is being proposed here, and reactionary grandstanding and spouting off about fourteen year olds who "can't keep their pants on" gets us pretty much nowhere.

This is a rather innocuous part of the bill, and Charlie's misquoting and misinterpretation of a small segment of a huge bill as a scare tactic is exactly why I think all of these calls for people to "read the bill" are not only likely to be useless or counterproductive

Well, I am not too proud to state when I am wrong, and clearly my interpretation was wrong. Thanks to eightgreenstreetcourt for setting me straight.

Please tell me then: as a comapny experiences turnover - people change jobs, move, whatnot - what do the new hires do for healthcare ... I mean, if a plan can't enroll new participants after the date that the grace period for phasing in the government mandated requirements begin .. how does the new gal/guy get insurance?

Following through, logically, even long-term employees will eventually be priced out of the empolyee-provided healthcare plans, because the pool of eligible (legacy) employees will dwindle over time, forcing the rates higher and higher.

And since the gov't plans have no 'expenses' as do private plans, it won't be long before the employers abandon the private plans in favor of the public one.

I...dam I just want to applaud this post and you for writing it. Truly, I agree with every word.

I have existing conditions, as does one of my children and we are hard to insure. (My husband has a small business.) We can afford our exorbitant insurance, but most people couldn't and that's just not okay. Something has to change.

No, you're actually wrong...all this is doing is defining a certain category of plan, which, if it wants to remain that kind of plan (a.k.a. within the definition of a GHIC), it can't change what it had on the threshold date or add new participants thereafter. The definition only has implications in how the statute applies or doesn't apply to such a plan. It has nothing to do with excluding people from other plans, and if you do in fact read through the proposal, there are a number of other ways that an existing private plans can continue to enroll people, so long as over time they comply with the requirements of the statute (i.e. they won't be allowed to exclude based on pre-existing conditions, have discriminative premiums, rescind cover without clear evidence of fraud, and they will have to provide certain basic benefits).

I'm not going to get into an economics based argument with you as I am not an economist and I have no way of predicting what insurance copanies or employers will do as a result of this legislation. As an attorney, however, I have seen in many other industries that when the government sets up a system or a set of rules governing a certain industry, private enterprise will often find ways to compete based on creative solutions and efficiencies that appeal to consumers and still make money (i.e. Wall Street is highly regulated). So as someone who understands this bill to basically be (1) setting arguably reasonable and fair requirements on an industry that has quite clearly spiraled out of control with its costs and its treatment of its customers, and (2) setting up a public alternative to said industry that may not be everything that a person of means could purchase privately but still provides a basic and equitable service to those who through circumstance or means cannot access the private sector, I believe that it does not, in fact, forecast the end of private insurance in any way.

Of course, the insurance companies would prefer to stay with the status quo, as it's never cheap or easy for them to comply with new regulatory requirements, especially ones counter to their exisiting business practices. Which is why they are spending millions on thier lobbying effort against this bill. But I have very little doubt that if it passes, they will in turn come up with competitive alternatives that will keep customers, even employers, knocking at their door. There are all sorts of private industries that do quite well competing with the government (private schools, private delivery services, private security firms, even private libraries, etc.). People who have the means will always pay for more than the statutory minimum, which is why I find any arguments that this will drive private insurers out of business to be specious. If they are a good busines with a smart, competitive business plan, they will survive. Isn't that really what the "free market" is all about? And if what they offer is required by the government to be fair and reasonable, then I say all the better.

It can't. If it adds new participants, then it simply does not qualify as a GHIC. That is all. If a plan wants to take on new participants, by all means it can. It just can't reap the benefits of the safe harbor afforded to a GHIC (unless the new particpants are dependants of existing plan members), which means that in turn it will no longer be a GHIC, and unless it qualifies for other exemptions, it will have to be subject to the requirements of the statute.

It can't. If it adds new participants, then it simply does not qualify as a GHIC. That is all. If a plan wants to take on new participants, by all means it can. It just can't reap the benefits of the safe harbor afforded to a GHIC

Thanks. You've gone to great lengths to demonstrate the folly of this particular section.

You've said you don't wish to discuss financials, but that's the 900 lb gorilla that needs to be discussed.

Here we have a private business, that pays its employees and shareholders, and it's policy holders, and is otherwise operating morally and ethically, suddenly forced to compete with an entity that is the US Federal gov't. An entity that has no profit/loss margin to worry about (well, certainly not in the sense any regular business does), that can raise revenue by tapping this seeminly unlimited cash supply from the Legislature, is accountable to no one, and who will have a pool of pre-paid policies without any marketing overhead simply by the stroke of a pen.

And with the system so geared that a business will either have to bear the brunt of the new plethora of federal laws, rules and oversight or accept the federal plan for it's employees, the private health insurance provider will face remarkable competetion, and undoubtedly lose policy holders in rigged market.

And when the insurance company cannot provide the same level of coverage for the price, they'll lose even more customers. Then people all over the country will suddenly find the company they've been told they can keep is going under, and those people will be told have no fear, the federal plan is here and that's when they'll realize the bill of goods that was sold to them: inferior, rationed coverage.

People mock the Medicaid and Medicare systems, and with good reason: instead of fixing them, we're running head-long, encouraging everyone (citizens and illegal immigrants alike) into the plan. That's a recipie for disaster.

Sure, the rich will always find a private solution, but then we'll still have 2-tiered system, but the divide will be so much greater.

The good news? The voters have begun to read the bills - both the House and the proposed Senate versions - and they see what is being sold to them. And they are not pleased.

@Charlie That's not even true. There are too many people in this country without health care. Children without health care of any kind. Saying there is free health care from our tax dollars is just an easy out.

Then there are the small business who can't afford to provide health care to their employees, who then can't afford it themselves either. What about those people? My brother works his ass off every day for his company. But he can't afford insurance and because his income is too high for it, he can't get free health care either. His health care plan is to pray he doesn't need health care.

Yes, there are people who have free health care through our tax dollars. However there is a HUGE portion of Americans who pay taxes and don't have health care.

No system is perfect. Health care in Canada is not perfect. But something has to change here. Our system isn't working.

= There are too many people in this country without health care. Children without health care of any kind. Saying there is free health care from our tax dollars is just an easy out. =

OK, this is a good start. Children having no health care of any kind is a MYTH! Show me one community anywhere in the US where children are unable to get any health care (possible exception: Appalachia, which is such a forgotten portion of the US it is in a separate class, and one that has long been under the radar and deserves attention). There is plenty of health care providers for kids that are free or next-to-free. We have SCHIP and many states (if not all) have state funded care directed to children. There's aid for dependent children, and on and on. Plus any person walking into any hospital will be treated.

What you've done is confused "health care" with "health insurance"... it's an easy mistake; after more than 2 years of campaigning for national health care, Mr. Obama switched the emphasis from 'health care' to 'health insurance' just in the last few weeks. I guess the term 'health care' didn't pass the focus groups as well as 'health insurance', huh?

=Then there are the small business who can't afford to provide health care to their employees, who then can't afford it themselves either. What about those people? My brother works his ass off every day for his company. But he can't afford insurance and because his income is too high for it, he can't get free health care either. His health care plan is to pray he doesn't need health care. =

And when the plan that President Obama is pushing goes through, his company will be taxed to cover the cost of covering EVERYONE and he may well LOSE that job because the hard-pressed small business that can't afford health insurance TODAY won't be able to afford the higher taxes TOMORROW.

=Yes, there are people who have free health care through our tax dollars. However there is a HUGE portion of Americans who pay taxes and don't have health care. =

Let's talk about the HUGE portion of Americans. The president is fond of claiming 47 million uninsured; how many are illegal? By most counts, 12-15 million. Strike them right off the bat. They violated our sovereignty getting here, they don't deserve another free ride.

Of the 32 million left, how many are rich that pay their own way? How many are the 20-somethings that carry no insurance (remember when we were that age and thought we were invincible?). How many others are in-between jobs, lacking coverage for the national average of 4 months? What you wind down to is about 12 million genuinely uninsured or uninsurable.

So when all the current polls show over 85% of all Americans are satisfied with their health care and insurance, and a small percentage are genuinely in need of a better public plan (as opposed to Medicare/Medicaid), you think overhauling the entire system is the best way?

=No system is perfect. Health care in Canada is not perfect. But something has to change here. Our system isn't working. =

Another emotional pull, but not true; the facts in the numbers say otherwise.

= Everyone does deserve health care. I believe it is a right.=

You may well believe that; is certainly doesn't make it so.

You're suggesting that after 230 years, this nation suddenly discovered it can't get by without a public health care?